Welfare, Abortion, and Organ Donation: A Reply to the Restrictivist

We argued in a recent issue of this journal that if abortion is restricted,1 then there are parallel obligations for parents to donate body parts to their children. The strength of this obligation to donate is proportional to the strength of the abortion restrictions. If abortion is never permissible, then a parent must always donate any organ if they are a match. If abortion is sometimes permissible and sometimes not, then organ donation is sometimes obligatory and sometimes not. Our argument was based on the following ideas: (a) that a fetus has full moral status, (b) that parents have special obligations to their offspring, fetus or not, and (c) that this special obligation is to protect them. The result is the conclusion that abortion restrictivists cannot also consistently deny that organ donation should be compulsory.

The ethical perspectives of using animals in pediatric health

While there are ethical standards for human biomedical research, animals have historically not benefitted from the same levels of protection. Cultural shifts in response to studies demonstrating animal capacity to suffer have resulted in laws defining minimum ethical standards for the treatment of various animal populations. However, none of these pertain to service or therapy animals nor do they define ethical considerations regarding training, placement, environment, and duty limitations specific to this population. The potential for harm and inability to provide consent should raise ethical questions of animal assisted interventions (AAI), including how to best balance the risk: benefit ratio for both animal and human participants. While service animals have specific definitions, therapy and emotional support animals are much less clearly defined and therefore have far less standardized practices regarding their training, certification, and process for matching to handlers. This can lead to animals being inadequately trained to cope with the stresses of their jobs or being placed in incompatible environments. Meanwhile, service animals' duties are constant, and the animal has little ability to consent to or withdraw from participation, leading to overwork, without the opportunity to engage in activities that align with the animals' natural preferences. Emotional support animals are the least defined of these populations, receive no formal training, and are at increased risk of inadequate care, unstable housing, and abuse from handlers who may also be poorly prepared to properly handle their needs. To uphold our moral obligations to the animals that serve to improve our own mental wellness and physical independence, urgent actions are needed to improve the protections in place for these populations.

Subgenome dominance shapes novel gene evolution in the decaploid pitcher plant Nepenthes gracilis

Subgenome dominance after whole-genome duplication generates distinction in gene number and expression at the level of chromosome sets, but it remains unclear how this process may be involved in evolutionary novelty. Here we generated a chromosome-scale genome assembly of the Asian pitcher plant Nepenthes gracilis to analyse how its novel traits (dioecy and carnivorous pitcher leaves) are linked to genomic evolution. We found a decaploid karyotype and a clear indication of subgenome dominance. A male-linked and pericentromerically located region on the putative sex chromosome was identified in a recessive subgenome and was found to harbour three transcription factors involved in flower and pollen development, including a likely neofunctionalized LEAFY duplicate. Transcriptomic and syntenic analyses of carnivory-related genes suggested that the paleopolyploidization events seeded genes that subsequently formed tandem clusters in recessive subgenomes with specific expression in the digestive zone of the pitcher, where specialized cells digest prey and absorb derived nutrients. A genome-scale analysis suggested that subgenome dominance likely contributed to evolutionary innovation by permitting recessive subgenomes to diversify functions of novel tissue-specific duplicates. Our results provide insight into how polyploidy can give rise to novel traits in divergent and successful high-ploidy lineages.

Bioelectrocatalytic Synthesis: Concepts and Applications

Bioelectrocatalytic synthesis is the conversion of electrical energy into value-added products using biocatalysts. These methods merge the specificity and selectivity of biocatalysis and energy-related electrocatalysis to address challenges in the sustainable synthesis of pharmaceuticals, commodity chemicals, fuels, feedstocks and fertilizers. However, the specialized experimental setups and domain knowledge for bioelectrocatalysis pose a significant barrier to adoption. This review introduces key concepts of bioelectrosynthetic systems. We provide a tutorial on the methods of biocatalyst utilization, the setup of bioelectrosynthetic cells, and the analytical methods for assessing bioelectrocatalysts. Key applications of bioelectrosynthesis in ammonia production and small-molecule synthesis are outlined for both enzymatic and microbial systems. This review serves as a necessary introduction and resource for the non-specialist interested in bioelectrosynthetic research.

C9orf72-ALS human iPSC microglia are pro-inflammatory and toxic to co-cultured motor neurons via MMP9

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive motor neuron loss, with additional pathophysiological involvement of non-neuronal cells such as microglia. The commonest ALS-associated genetic variant is a hexanucleotide repeat expansion (HRE) mutation in C9orf72. Here, we study its consequences for microglial function using human iPSC-derived microglia. By RNA-sequencing, we identify enrichment of pathways associated with immune cell activation and cyto-/chemokines in C9orf72 HRE mutant microglia versus healthy controls, most prominently after LPS priming. Specifically, LPS-primed C9orf72 HRE mutant microglia show consistently increased expression and release of matrix metalloproteinase-9 (MMP9). LPS-primed C9orf72 HRE mutant microglia are toxic to co-cultured healthy motor neurons, which is ameliorated by concomitant application of an MMP9 inhibitor. Finally, we identify release of dipeptidyl peptidase-4 (DPP4) as a marker for MMP9-dependent microglial dysregulation in co-culture. These results demonstrate cellular dysfunction of C9orf72 HRE mutant microglia, and a non-cell-autonomous role in driving C9orf72-ALS pathophysiology in motor neurons through MMP9 signaling.

A cytochrome P450 CYP87A4 imparts sterol side-chain cleavage in digoxin biosynthesis

Digoxin extracted from the foxglove plant is a widely prescribed natural product for treating heart failure. It is listed as an essential medicine by the World Health Organization. However, how the foxglove plant synthesizes digoxin is mostly unknown, especially the cytochrome P450 sterol side chain cleaving enzyme (P450scc), which catalyzes the first and rate-limiting step. Here we identify the long-speculated foxglove P450scc through differential transcriptomic analysis. This enzyme converts cholesterol and campesterol to pregnenolone, suggesting that digoxin biosynthesis starts from both sterols, unlike previously reported. Phylogenetic analysis indicates that this enzyme arises from a duplicated cytochrome P450 CYP87A gene and is distinct from the well-characterized mammalian P450scc. Protein structural analysis reveals two amino acids in the active site critical for the foxglove P450scc's sterol cleavage ability. Identifying the foxglove P450scc is a crucial step toward completely elucidating digoxin biosynthesis and expanding the therapeutic applications of digoxin analogs in future work.

Extracting Data from the Electronic Health Record of Patients with ADHD Reveals Pediatricians' Discussions of Educational Support and Document Collection

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR). There was no association between having an educational document uploaded into the EHR and inclusion of a term related to educational support in a note. Almost half (48 percent) of these records were unclearly labeled. Further education of PCPs is warranted to increase discussions of educational support and obtaining educational records, as is collaboration with health information management professionals around labeling.

Multi-source datasets acquired over Toulouse (France) in 2021 for urban microclimate studies during the CAMCATT/AI4GEO field campaign

The CAMCATT-AI4GEO extensive field experiment took place in Toulouse, a city in the southwest of France, from 14^th to 25^th June 2021 (with complementary measurements performed on the 6 September 2021). Its main objective was the acquisition of a new reference dataset on an urban site to support the development and validation of data products from the future thermal infrared (TIR) satellite missions such as TRISHNA (CNES/ISRO), LSTM (ESA) and SBG (NASA). With their high spatial (between 30-60m) and temporal (2-3 days) resolutions, the future TIR satellite data will allow a better investigation of the urban climate at the neighbourhood scale. However, in order to validate the future products of these missions such as LST, air temperature, comfort index and Urban Heat Island (UHI), there is a need to accurately characterise the organisation of the city in terms of 3D geometry, spectral optical properties and both land surface temperature and emissivity (LST and LSE) at several scales. In this context, the CAMCATT-AI4GEO field campaign provides a set of airborne VISNIR-SWIR (Visible Near InfraRed - ShortWave InfraRed) hyperspectral imagery, multispectral thermal infrared (TIR) imagery and 3D LiDAR acquisitions, together with a variety of ground data collected, for some of them, simultaneously to the flight. The ground dataset includes surface reflectance measured spectrally with ASD spectroradiometers and in six spectral bands spreading from shortwave to thermal infrared and for two viewing angles with a SOC410-DHR handheld reflectometer. It is completed with LST and LSE retrieved from thermal infrared radiance acquired in six spectral bands with CIMEL radiometers. It also includes meteorological data coming from four radio soundings (one of which was taken during the flight), data routinely collected at the Blagnac airport reference station as well as air temperature and humidity acquired using instrumented cars following two different itineraries. In addition, a link is provided to access the data routinely collected by the network of weather stations set up by Toulouse Metropole in the city and its surroundings. This data paper describes this new reference urban dataset which can be useful for many applications such as calibration/validation of at-surface radiance, LST and LSE data products as well as higher level products such as air temperature or comfort index. It also provides valuable opportunities for other applications in urban climate studies, such as supporting the validation of microclimate models.

Cardenolide Increase in Foxglove after 2,1,3-Benzothiadiazole Treatment Reveals a Potential Link between Cardenolide and Phytosterol Biosynthesis

Cardenolides are steroidal metabolites in Digitalis lanata with potent cardioactive effects on animals. In plants, cardenolides are likely involved in various stress responses. However, the molecular mechanism of cardenolide increase during stresses is mostly unknown. Additionally, cardenolides are proposed to arise from cholesterol, but indirect results show that phytosterols may also be substrates for cardenolide biosynthesis. Here, we show that cardenolides increased after methyl jasmonate (MJ), sorbitol, potassium chloride (KCl) and salicylic acid analog [2,1,3-benzothiadiazole (BTH)] treatments. However, the expression of three known genes for cardenolide biosynthesis did not correlate well with these increases. Specifically, the expression of progesterone-5β-reductases (P5βR and P5βR2) did not correlate with the cardenolide increase. The expression of 3β-hydroxysteroid dehydrogenase (3βHSD) correlated with changes in cardenolide levels only during the BTH treatment. Mining the D. lanata transcriptome identified genes involved in cholesterol and phytosterol biosynthesis: C24 sterol sidechain reductase 1 (SSR1), C4 sterol methyl oxidase 1, and 3 (SMO1 and SMO3). Surprisingly, the expression of all three genes correlated well with the cardenolide increase after the BTH treatment. Phylogenetic analysis showed that SSR1 is likely involved in both cholesterol and phytosterol biosynthesis. In addition, SMO1 is likely specific to phytosterol biosynthesis, and SMO3 is specific to cholesterol biosynthesis. These results suggest that stress-induced increase of cardenolides in foxglove may correlate with cholesterol and phytosterol biosynthesis. In summary, this work shows that cardenolides are important for stress responses in D. lanata and reveals a potential link between phytosterol and cardenolide biosynthesis.

Biological anolyte regeneration system for redox flow batteries

Redox flow battery (RFB) electrolyte degradation is a common failure mechanism in RFBs. We report an RFB using genetically engineered, phenazine-producing Escherichia coli to serve as an anolyte regeneration system capable of repairing the degraded/decomposed redox-active phenazines. This work represents a new strategy for improving the stability of RFB systems because, under the influence of genetically engineered microbes, the anolyte species does not display degradation after battery cycling.

Targeting phosphoglycerate kinase 1 with terazosin improves motor neuron phenotypes in multiple models of amyotrophic lateral sclerosis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder with heterogeneous aetiology and a complex genetic background. Effective therapies are therefore likely to act on convergent pathways such as dysregulated energy metabolism, linked to multiple neurodegenerative diseases including ALS.

METHODS

Activity of the glycolysis enzyme phosphoglycerate kinase 1 (PGK1) was increased genetically or pharmacologically using terazosin in zebrafish, mouse and ESC-derived motor neuron models of ALS. Multiple disease phenotypes were assessed to determine the therapeutic potential of this approach, including axon growth and motor behaviour, survival and cell death following oxidative stress.

FINDINGS

We have found that targeting a single bioenergetic protein, PGK1, modulates motor neuron vulnerability in vivo. In zebrafish models of ALS, overexpression of PGK1 rescued motor axon phenotypes and improved motor behaviour. Treatment with terazosin, an FDA-approved compound with a known non-canonical action of increasing PGK1 activity, also improved these phenotypes. Terazosin treatment extended survival, improved motor phenotypes and increased motor neuron number in Thy1-hTDP-43 mice. In ESC-derived motor neurons expressing TDP-43^M337V, terazosin protected against oxidative stress-induced cell death and increased basal glycolysis rates, while rescuing stress granule assembly.

INTERPRETATION

Our data demonstrate that terazosin protects motor neurons via multiple pathways, including upregulating glycolysis and rescuing stress granule formation. Repurposing terazosin therefore has the potential to increase the limited therapeutic options across all forms of ALS, irrespective of disease cause.

FUNDING

This work was supported by project grant funding from MND Scotland, the My Name'5 Doddie Foundation, Medical Research Council Doctoral Student Training Fellowship [Ref: BST0010Z] and Academy of Medical Sciences grant [SGL023\1100].

Metabolic disease and adverse events from immune checkpoint inhibitors

OBJECTIVE

Obese and overweight body mass index (BMI) categories have been associated with increased immune-related adverse events (irAEs) in patients with cancer receiving immune checkpoint inhibitors (ICIs); however, the impact of being overweight in conjunction with related metabolic syndrome-associated factors on irAEs have not been investigated. We aimed to evaluate the impact of overweight and obese BMI according to metabolic disease burden on the development of irAEs.

DESIGN AND METHODS

We conducted a retrospective observational study of patients receiving ICIs at a cancer center. Our main study outcome was development of ≥grade 2 (moderate) irAEs. Our main predictor was weight/metabolic disease risk category: (1) normal weight (BMI 18.5-24.9 kg/m²)/low metabolic risk (<2 metabolic diseases [diabetes, dyslipidemia, hypertension]), (2) normal weight/high metabolic risk (≥2 metabolic diseases), (3) overweight (BMI ≥25 kg/m²)/low metabolic risk, and (4) overweight/high metabolic risk.

RESULTS

Of 411 patients in our cohort, 374 were eligible for analysis. Overall, 111 (30%) patients developed ≥grade 2 irAEs. In Cox analysis, overweight/low metabolic risk was significantly associated with ≥grade 2 irAEs (hazard ratio [HR]: 2.0, 95% confidence interval [95% CI]: 1.2-3.4) when compared to normal weight/low metabolic risk, while overweight/high metabolic risk (HR: 1.3, 95% CI: 0.7-2.2) and normal weight/high metabolic risk (HR: 1.5, 95% CI: 0.7-3.0) were not.

CONCLUSIONS

Overweight patients with fewer metabolic comorbidities were at increased risk for irAEs. This study provides an important insight that BMI should be evaluated in the context of associated metabolic comorbidities in assessing risk of irAE development and ICI immune response.

Implementation of office-based buprenorphine treatment for opioid use disorder

BACKGROUND

Buprenorphine-based medication-assisted treatment (B-MAT) is a powerful, concrete intervention that can be provided by nurse practitioners (NPs) to reduce opioid-related overdoses in patients with opioid use disorder (OUD). However, multiple barriers exist to provide and access this therapy.

LOCAL PROBLEM

A rural Midwestern county struggled with increasing OUD and scant access to B-MAT. A nurse-led, community clinic had the potential to expand access to treatment but no support structure to provide it.

METHODS

In this quality improvement project, a one-group posttest-only design was used to assess treatment access, care quality, and patient characteristics.

INTERVENTIONS

An evidence-based, nurse led weekly B-MAT clinic using a low-threshold, chronic-care model for treatment of OUD.

RESULTS

The B-MAT clinic expanded county-wide access by 34% over seven months. A total of 23 patients were seen with 21 eligible for treatment with B-MAT. All nine patients with at least 90-day continuous treatment were retained in the program. Three quarters of patients had at least 30 days of active buprenorphine-naloxone coverage and 17% of all patients were lost to follow up. There were no induction-related adverse events, no fatalities, and one nonfatal overdose. In a chart review, 85% of patients met at least six of eight quality criteria.

CONCLUSIONS

This low-barrier approach to OUD expanded access to treatment and demonstrated a model stable enough to continue delivering care throughout the first 5 months of the novel coronavirus (COVID-19) pandemic. NPs in primary care settings can effectively provide B-MAT in a low-threshold, office-based setting.

Characterization of hyperglycemia in patients receiving immune checkpoint inhibitors: Beyond autoimmune insulin-dependent diabetes

AIMS

Immune-mediated beta cell destruction is known to cause hyperglycemia in patients receiving immune checkpoint inhibitor (ICI) cancer therapy. However, it is uncommon, and little is known about the full spectrum of hyperglycemia in patients receiving ICIs. We aimed to characterize the prevalence and factors associated with hyperglycemia in patients treated with ICIs.

METHODS

We retrospectively analyzed patients receiving ICIs at an NCI-designated Cancer Center. We assessed the proportion of patients with new onset hyperglycemia (random glucose >11.1 mmol/L) after starting ICIs and used logistic regression to determine hyperglycemia predictors in patients without known diabetes.

RESULTS

Of 411 patients, 385 had post-ICI glucose data. 105 (27%) had hyperglycemia. Of this group, 29 (28%) had new onset hyperglycemia, 19 of whom had glucocorticoid-associated hyperglycemia. The remaining 10 had unexplained hyperglycemia and none had known autoimmune diabetes. Among patients without known diabetes, race/ethnicity, obesity, and pre-ICI hyperglycemia were significantly associated with hyperglycemia after starting ICIs.

CONCLUSIONS

We found that new hyperglycemia in patients receiving ICIs was most commonly related to glucocorticoids. A small patient subset had new unexplained hyperglycemia, suggesting ICIs might have a role in promoting hyperglycemia. Recognizing factors associated with hyperglycemia in this population is crucial for appropriate management.

Durable disease control with local treatment for oligoprogression of metastatic solid tumors treated with immune checkpoint blockade

BACKGROUND

While the concept of oligometastatic disease is increasingly recognized as a distinct clinical disease state, the concept of oligoprogression is less well-characterized. Oligoprogression may be particularly relevant in the context of immune checkpoint inhibitors (CPI) given the underlying mechanism of action and insights regarding acquired resistance. In this study, we sought to characterize the incidence of oligoprogression in patients on CPI and explore the impact of local therapy.

MATERIALS AND METHODS

We performed a retrospective analysis of all patients with advanced solid tumors (excluding glioblastoma multiforme) who received a PD-1, PD-L1, or CTLA-4 inhibitor at a single institution between 2011 and 2017. Oligoprogression was defined as progression at ≤3 metastatic lesions outside of the brain after achieving at least stable disease on CPI for 3 months. Progression-free survival (PFS) was calculated using the Kaplan-Meier method.

RESULTS

Among 425 patients treated with CPI, 390 had advanced primary solid tumors outside of the central nervous system. 321 of these patients were evaluable for response, among whom 102 achieved at least stable disease. Oligoprogression was observed in 4.1% of the entire cohort and 15.7% of patients achieving at least stable disease on CPI. Among 16 patients experiencing oligoprogression, 15 received local therapy to the oligoprogressive lesions, many of whom continued CPI. At a median follow-up of 25.8 months, the median PFS for patients with oligoprogression after local therapy was 15.4 months.

CONCLUSIONS

Oligoprogression occurs in a subset of patients after an initial response to CPI. However, patients receiving local therapy to oligoprogressive sites may experience durable disease control. Further study is warranted.

MICROABSTRACT

Oligoprogression was observed in 4.1% of the entire cohort of patients on immune checkpoint inhibitors in this study and 15.7% of patients achieving at least stable disease. Among 16 patients experiencing oligoprogression, 15 received local therapy. At a median follow-up of 25.8 months, the median progression-free survival for patients with oligoprogression after local therapy was 15.4 months and zero patients had died. Oligoprogression occurs in a subset of patients after an initial response to CPI and local therapy to oligoprogressive sites may result in durable disease control.

A transient role of the ciliary gene Inpp5e in controlling direct versus indirect neurogenesis in cortical development

During the development of the cerebral cortex, neurons are generated directly from radial glial cells or indirectly via basal progenitors. The balance between these division modes determines the number and types of neurons formed in the cortex thereby affecting cortical functioning. Here, we investigate the role of primary cilia in controlling the decision between forming neurons directly or indirectly. We show that a mutation in the ciliary gene Inpp5e leads to a transient increase in direct neurogenesis and subsequently to an overproduction of layer V neurons in newborn mice. Loss of Inpp5e also affects ciliary structure coinciding with reduced Gli3 repressor levels. Genetically restoring Gli3 repressor rescues the decreased indirect neurogenesis in Inpp5e mutants. Overall, our analyses reveal how primary cilia determine neuronal subtype composition of the cortex by controlling direct versus indirect neurogenesis. These findings have implications for understanding cortical malformations in ciliopathies with INPP5E mutations.

SAT-411 Vitamin D Levels and Risk of Thyroid Immune Related Adverse Events in Patients on Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICI), such as monoclonal antibodies to cytotoxic T lymphocyte associated protein 4 (CTLA-4), programmed cell death 1 (PD-1) and PD ligand 1 (PD-L1) are recognized as effective cancer-directed therapies. Yet, ICI-induced activation of the immune system results in immune-related adverse events (irAEs) affecting many organs, including the thyroid. Separately, Vitamin D (Vit D) deficiency has been associated with increased risk of autoimmune thyroid disease. We hypothesized that patients who were Vit D deficient at the time of initiating ICI therapy would be more likely to develop thyroid irAEs. We retrospectively collected data for 411 patients who received ICIs at our institution between January 2011 and April 2017. We then identified 91 of these patients who had 25-OH Vit D levels obtained; 2 were excluded from analysis due to previous thyroidectomy. We recorded demographics, cancer type, Vit D level closest to the start date of ICI therapy, and thyroid irAEs. Patients were categorized as Vit D deficient (&lt;20ng/mL), insufficient (20-29.9ng/mL) or sufficient (≥30ng/mL). We compared patient demographic and clinical characteristics between the VitD categories. Proportions were compared using Fisher’s Exact Test. Of the 89 patients, 48.3% were female and 51.7% were male. Mean age was 67.2 (SD±10.6) years with 57% white, 8% black, 10% hispanic, 7% Asian, and 18% other / unknown. 20% of patients had non-small cell lung cancer, 15% melanoma, 13% hepatocellular carcinoma, 12% multiple myeloma (MM), 8% renal cell carcinoma (RCC), 7% head and neck squamous cell carcinoma, 7% urothelial carcinoma and 18% other cancer types. 21.3% were Vit D deficient, 40.4% were insufficient, and 38.2% were sufficient. Patients with Vit D deficiency and insufficiency were younger (age 64.1± 11.7, 65.9±9.5 years, respectively) than the Vit D sufficiency group (70.1±10.5years, p=0.046). No significant differences between males and females were observed between Vit D categories. Across cancer types, the highest prevalence of Vit D deficiency was in RCC (42.9%) and MM (36.4%). Hispanic and Asian patients had the highest prevalence of Vit D deficiency (44.4% and 33.3%, respectively). 11 patients (12.4%) developed a thyroid irAE. Thyroid irAEs occurred in 5.3% with Vit D deficiency, 8.1% with Vit D insufficiency, and 20% with Vit D sufficiency, but the association was not statistically significant (p=0.2). In contrast to our hypothesis, Vit D deficiency was not associated with a higher rate of thyroid irAEs. In fact our data suggest that patients who are vitamin D sufficient at the time of starting ICI therapy may be at greater risk of developing thyroid irAEs. Our study is limited by small numbers and the retrospective nature of the study. Prospective studies should be performed to determine the significance of Vit D levels on ICI related thyroid disease.

Characterizing patterns of disease progression in patients with genitourinary cancers treated with immune checkpoint inhibitors

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Background: Despite the widespread use of immune checkpoint inhibitors (ICIs), patterns of disease progression (POD) are poorly characterized. We aim to define these characteristics in patients (pts) with advanced urothelial carcinoma (UC) and renal cell carcinoma (RCC) treated with ICIs. Methods: We retrospectively reviewed charts of pts with advanced UC and RCC who received at least 2 ICI doses at our institution from 12/1/10 – 10/31/18. Demographics, medical history, ICI course, toxicity, and outcomes were recorded. Characteristics at the time of radiographic POD including location of metastases (mets), symptoms (sx), and hospitalization details were collected. Fisher’s exact test was used to study differences in pts with and without hospitalization at POD. Results: Of the 71 pts identified (UC N=53; RCC N=18), 59 pts had POD. At POD, 19 (32.2%) pts had new sites of disease involvement, while the remaining pts (N=40, 67.8%) had progression only at previously known sites of disease. Fourty-six (78.0%) pts had sx at POD: 1 sx (N=19, 32.2%), 2 sx (N=13, 22.0%), 3+ sx (N=14, 23.7%). Pain was the most common sx at POD (N=32, 54.2%), followed by loss of energy (N=18, 30.5%), and loss of appetite (N=14, 23.7%). Twenty-five (42.4%) pts were hospitalized at POD, most commonly for sepsis (N=8, 32%). No clinical factors were identified to predict for pts being hospitalized at POD. Conclusions: In our review of GU cancer patients on ICIs, a large proportion of pts reported clinical sx at POD, pain being the most frequent. Furthermore, a substantial number of pts were hospitalized at POD, most commonly for sepsis. Thus, further studies are warranted to confirm these findings, and potentially identify strategies to optimize patients’ quality-of-life and reduce rates of hospitalizations at the time of POD on ICIs.

Type, timing, and risk factors associated with immune-related adverse event development in patients with advanced genitourinary cancers treated with immune checkpoint inhibitor

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Background: Immune related adverse events (IRAEs) with immune checkpoint inhibitor (ICI) therapy are well recognized, but predictors for IRAEs are not well defined. We aim to characterize the type, timing, and clinical risk factors associated with (w/) IRAEs in ICI-treated, advanced urothelial carcinoma (UC) and renal cell carcinoma (RCC) patients (pts). Methods: We retrospectively reviewed charts of pts w/ advanced UC and RCC who received at least 2 ICI doses at our institution from 1/1/10 to 10/31/18. Patient baseline characteristics, treatment course, and clinical outcomes were collected. IRAEs were identified and graded (GR) based on CTCAE (v.4.0). Fisher’s exact test was used to study the differences between pts w/ versus without IRAE. Results: Of the 71 pts identified (UC n = 53; RCC n = 18), 27 pts (38%) developed IRAEs with 42 total events (38% GR1, 60% GR2, and 2% GR≥3) [table]. The majority of pts with dermatitis (70%) also developed a secondary, systemic IRAE(s). Systemic steroid (SS) was required in 17 events. The median time to any IRAE was 17.5 weeks (w, range 1-93). ECOG ≤ 1 predicted IRAE development (p < 0.05). No other characteristics (demographics, co-morbidities, metastatic sites, ICI type, line of therapy, and duration of ICI > 12w) were associated with IRAE. Conclusions: In our study, good function status is associated with the development of IRAE. Time to IRAE ranged from immediately to 93w after initiating ICI. Clinical validation with additional datasets will be needed to confirm these findings. [Table: see text]

Barriers and Facilitators in the Recruitment and Retention of More Than 250 Small Independent Primary Care Practices for EvidenceNOW

Few studies have examined factors that facilitate recruitment of small independent practices (SIPs) (<5 full-time clinicians) to participate in research and methods for optimizing retention. The authors analyzed qualitative data (eg, recruiter's field notes and diary entries, provider interviews) to identify barriers and facilitators encountered in recruiting and retaining 257 practices in HealthyHearts New York City (NYC). This study was a stepped-wedge randomized controlled trial that took place 2015 through 2018 across 5 boroughs in NYC. Three main factors facilitated rapid recruitment: (1) a prior well-established relationship with the local health department, (2) alignment of project goals with practice priorities, and (3) providing appropriate monetary incentives. Retention was facilitated through similar mechanisms and an ongoing multifaceted communication strategy. This article identifies specific strategies that enhance recruitment of SIPs and fills gaps in knowledge about factors that influence retention in the context of a design that requires waiting to receive the intervention.

SAT-094 Overweight and Obesity Associated with Immune-Related Adverse Events in Patients on Immune Checkpoint Inhibitor Therapy

Background As immune checkpoint inhibitor (ICI) therapies (PD(L)1 and CTLA-4 inhibitors) are increasingly used for treating malignancy, immune-related adverse events (irAEs) are being encountered by clinicians more frequently. Obesity is a pro-inflammatory metabolic state that has been associated with a higher risk of developing autoimmune disease, but its role in irAEs in patients treated with ICIs is not well characterized. Hypothesis We hypothesized that patients on ICI therapy who were overweight or obese would be more likely to have a grade 2 or greater irAE compared to normal or underweight patients. Methods We retrospectively collected clinical data for 398 cancer patients with baseline body mass index (BMI) data who received ICIs between January 2011 and April 2017 at our institution. Patients were categorized as having lower BMI (low or normal weight, <25) or higher BMI (obese or overweight, ≥25). An irAE was defined as an AE during ICI therapy that was ≥ Grade 2 according to the Common Terminology Criteria for AEs. We compared patient demographic and clinical characteristics between BMI categories. To determine if BMI category was associated with irAEs, we used multivariate logistic regression. Demographics and variables significantly associated with irAEs were included in the model. Results 201 (50.5%) of patients had lower BMI and 197 (49.5%) had higher BMI. 98 patients (24.6%) had an irAE and median follow up time was 8.7 months. The most common malignancies were melanoma (19.6%), non-small cell lung cancer (23.7%), hepatocellular carcinoma (14.6%), and urothelial carcinoma (12.3%). Patients were treated with blockade of CTLA-4 (11.8%), PD1/PDL1, (77.9%), combination of CTLA-4 and PD(L)1 blockade concurrently (4.0%), and sequentially (6.3%). Patients with lower and higher BMI did not differ significantly in respect to age, gender, clinical stage, or category of ICI. Race differed significantly between high vs low BMI categories, (White 60.4% vs 47.3%, Black 8.1% vs 11.9%, Hispanic 11.7% vs 8%, Asian 3.6% vs 11.9%, Unknown/other 16.2% vs 20.9%, p<0.01). Patients with higher BMI were more likely to have a preexisting autoimmune disease (10.8% vs 7.5%, p=0.04). Higher BMI was significantly associated with irAEs (odds ratio (OR) 1.79, 95% confidence interval (CI) 1.09-2.96 in a model adjusted for age, gender, race, ICI category, and preexisting autoimmune disease. Other race (compared to white race) (OR 0.40, 95% CI 0.19-0.83, PD(L)1 blockade (compared to CTLA-4 blockade) (OR 0.49, 95% CI 0.24-0.99), and preexisting autoimmune disease (OR 2.8, 95% CI 1.4-5.7) were also significant predictors of irAEs in the adjusted model. Conclusions Being overweight or obese was associated with irAEs in patients on ICI therapy. Insights into how BMI mediates the immune effects of ICI therapy can potentially elucidate how inflammation plays a role in the metabolic sequelae of obesity and adiposity.

MON-603 Racial Distribution of Endocrine Complications in Oncology Patients Treated with Immune Checkpoint Inhibitors

Background: Immune-related adverse events (irAEs) have been frequently described with the growing use of immune checkpoint inhibitors (ICI) in cancer treatment. While many autoimmune diseases are known to be more prevalent in certain racial groups, it is unknown if there are racial disparities in the rate of irAEs. Clinical trials reporting irAEs thus far have not explored their distribution in underrepresented minorities. It is important to study irAEs in racially diverse populations to better understand which patients are more likely to be impacted. Hypothesis: We sought to describe the demographics of a diverse cohort of patients treated with ICIs, as well as the racial distribution of irAEs. We hypothesized that there would be a significant difference among self-reported races experiencing ICI-related endocrine diseases. Methods: IRB approval was obtained to identify 411 oncology patients who were treated with ICIs between January 2011 and April 2017 from an EMR-based data repository. We collected data on age, gender, BMI, comorbidities, and median follow up time, which were further stratified according to self-identified race (White, Black, Hispanic, Asian, Other/Unknown). Endocrine adverse events were recorded according to race and were defined as events that were ≥ Grade 2 according to the Common Terminology Criteria for Adverse Events. We used the Fisher exact test for categorical variables and the Kruskal-Wallis test for continuous variables in the comparative analyses. Results: Of 411 patients treated with ICIs, 53.3% were White, 10.2% were Black, 10.5% were Hispanic, 7.5% were Asian, and 18.5% were Other/Unknown. The mean age was 65.3 years (67.8 in Whites, 63.7 in Blacks, 62.2 in Hispanics, 60.5 in Asians, 62.8 in Other/Unknown; p=0.0012). 38.4% were Female and 61.6% were Male. Mean BMI was 25.9 kg/m². 10.9% of all patients had pre-existing autoimmune disease (White: 11.0%, Black: 9.5%, Hispanic: 11.6%, Asian: 0, Other/Unknown: 15.8%; p=0.164). 7.3% of all patients had pre-existing thyroid disease (White: 6.9%, Black: 7.1%, Hispanic: 7.0%, Asian: 0, Other/Unknown: 11.8%; p=0.311). Mean follow up period was 8.7 months. 54 (13.1%) patients experienced any endocrine adverse effect without a statistically significant difference among racial groups (White: 16.0%, Black: 16.7%, Hispanic: 11.6%, Asian: 6.5%, Other/Unknown: 6.6%; p=0.189). 14.8% developed hypophysitis, 70.4% developed thyroid disease, 13.0% developed adrenal insufficiency, and 1.9% developed diabetes. Conclusions: Self-reported race was not associated with the development of ICI-related endocrinopathies in a diverse group of oncology patients. Further studies are needed to continue to characterize the populations experiencing immune-related endocrine complications in ICI therapy.

Trends in United States Mass Fatality Incidents and Recommendations for Medical Examiners and Coroners

It is imperative that medicolegal jurisdictions prepare for the occurrence of a mass fatality incident. Despite the trend to plan for catastrophic and complicated incidents, this analysis of recent mass fatality events seeks to better inform authorities regarding the scale and types of incidents that could potentially impact their jurisdiction. The guidance provided by this study serves as a tool to guide the development of plans, acquisition of appropriate resources, and training of staff. To perform this analysis, data were collected from mass fatality incidents occurring in the United States from January 1, 2000 to December 31, 2016 that resulted in ten or more fatalities. Specific data points were collected for each incident including the date, location, number of fatalities, incident type (e.g., man-made or natural), incident subtype, and description (e.g., mass shooting, hurricane, aviation). A total of 137 incidents fit the criteria for inclusion in the analysis, resulting in a total of 8462 fatalities. The average number of incidents was eight per year during the study period. The analysis demonstrates that most mass fatality incidents (88.8%) result in between ten and 50 fatalities and are variable based on incident type and geographic location. This study includes several large-scale incidents, which as outliers have influenced fatality management operations and preparedness efforts on a national level. In particular, the World Trade Center attack of September 11, 2001 and subsequent remains recovery and identification operations have served to inform the New York City Office of Chief Medical Examiner of the capabilities required to manage a complex, protracted victim identification process involving extensive body fragmentation and commingling. While the World Trade Center attack has been shown to be outside the normal trends of mass fatality incidents, it has nonetheless offered the medicolegal community several invaluable lessons.

Sleep apnea: a review of diagnostic sensors, algorithms, and therapies

While public awareness of sleep related disorders is growing, sleep apnea syndrome (SAS) remains a public health and economic challenge. Over the last two decades, extensive controlled epidemiologic research has clarified the incidence, risk factors including the obesity epidemic, and global prevalence of obstructive sleep apnea (OSA), as well as establishing a growing body of literature linking OSA with cardiovascular morbidity, mortality, metabolic dysregulation, and neurocognitive impairment. The US Institute of Medicine Committee on Sleep Medicine estimates that 50-70 million US adults have sleep or wakefulness disorders. Furthermore, the American Academy of Sleep Medicine (AASM) estimates that more than 29 million US adults suffer from moderate to severe OSA, with an estimated 80% of those individuals living unaware and undiagnosed, contributing to more than $149.6 billion in healthcare and other costs in 2015. Although various devices have been used to measure physiological signals, detect apneic events, and help treat sleep apnea, significant opportunities remain to improve the quality, efficiency, and affordability of sleep apnea care. As our understanding of respiratory and neurophysiological signals and sleep apnea physiological mechanisms continues to grow, and our ability to detect and process biomedical signals improves, novel diagnostic and treatment modalities emerge.

OBJECTIVE

This article reviews the current engineering approaches for the detection and treatment of sleep apnea.

APPROACH

It discusses signal acquisition and processing, highlights the current nonsurgical and nonpharmacological treatments, and discusses potential new therapeutic approaches.

MAIN RESULTS

This work has led to an array of validated signal and sensor modalities for acquiring, storing and viewing sleep data; a broad class of computational and signal processing approaches to detect and classify SAS disease patterns; and a set of distinctive therapeutic technologies whose use cases span the continuum of disease severity.

SIGNIFICANCE

This review provides a current perspective of the classes of tools at hand, along with a sense of their relative strengths and areas for further improvement.

Comprehensive analysis of fungal diversity and enzyme activity in nuruk, a Korean fermenting starter, for acquiring useful fungi

Nuruk is a fermenting starter that is involved in the production of alcoholic beverages, and has been used in South Korea for a very long time. To analyze the fungal diversity, we collected a total of 59 nuruk samples from several companies and persons in 2013 to 2014, and obtained 364 isolates. All of the single isolated fungi were identified, both morphologically and molecularly, based on the sequences of ribosomal RNA gene [18S, ITS1-5.8S-ITS2, and 26S (D1/D2 region)]. In 46 nuruk samples out of 59 (78%), Saccharomycopsis fibuligera, a dimorphic yeast, was most frequently isolated. Among the filamentous fungi, Aspergillus and Lichtheimia were found in more than 50% of the samples with lower colony forming unit (CFU/g of sample) than those of yeasts. The yeasts S. fibuligera and Wickerhamomyces anomalus were counted with maximum 1.3-1.8 × 10⁸ CFU/g. Among Mucorales fungi, Lichtheimia and Mucor were isolated in much higher numbers than Rhizopus and Rhizomucor. Overall, the home-made nuruks tend to contain more diverse filamentous fungi than the commercial nuruks. To acquire industrially useful filamentous fungi and yeasts, we analyzed the enzyme activities of α-amylase, glucoamylase and acid protease associated with brewing properties for 131 strains. Aspergillus oryzae and S. fibuligera had high α- and glucoamylase activities and most isolates of Lichtheimia ramosa had high acid protease activity. For further applications, 27 fungal strains were chosen based on isolation frequencies from nuruk, and the ability to produce useful enzyme.

Whole-genome de novo sequencing, combined with RNA-Seq analysis, reveals unique genome and physiological features of the amylolytic yeast Saccharomycopsis fibuligera and its interspecies hybrid

BACKGROUND

Genomic studies on fungal species with hydrolytic activity have gained increased attention due to their great biotechnological potential for biomass-based biofuel production. The amylolytic yeast Saccharomycopsis fibuligera has served as a good source of enzymes and genes involved in saccharification. Despite its long history of use in food fermentation and bioethanol production, very little is known about the basic physiology and genomic features of S. fibuligera.

RESULTS

We performed whole-genome (WG) de novo sequencing and complete assembly of S. fibuligera KJJ81 and KPH12, two isolates from wheat-based Nuruk in Korea. Intriguingly, the KJJ81 genome (~38 Mb) was revealed as a hybrid between the KPH12 genome (~18 Mb) and another unidentified genome sharing 88.1% nucleotide identity with the KPH12 genome. The seven chromosome pairs of KJJ81 subgenomes exhibit highly conserved synteny, indicating a very recent hybridization event. The phylogeny inferred from WG comparisons showed an early divergence of S. fibuligera before the separation of the CTG and Saccharomycetaceae clades in the subphylum Saccharomycotina. Reconstructed carbon and sulfur metabolic pathways, coupled with RNA-Seq analysis, suggested a marginal Crabtree effect under high glucose and activation of sulfur metabolism toward methionine biosynthesis under sulfur limitation in this yeast. Notably, the lack of sulfate assimilation genes in the S. fibuligera genome reflects a unique phenotype for Saccharomycopsis clades as natural sulfur auxotrophs. Extended gene families, including novel genes involved in saccharification and proteolysis, were identified. Moreover, comparative genome analysis of S. fibuligera ATCC 36309, an isolate from chalky rye bread in Germany, revealed that an interchromosomal translocation occurred in the KPH12 genome before the generation of the KJJ81 hybrid genome.

CONCLUSIONS

The completely sequenced S. fibuligera genome with high-quality annotation and RNA-Seq analysis establishes an important foundation for functional inference of S. fibuligera in the degradation of fermentation mash. The gene inventory facilitates the discovery of new genes applicable to the production of novel valuable enzymes and chemicals. Moreover, as the first gapless genome assembly in the genus Saccharomycopsis including members with desirable traits for bioconversion, the unique genomic features of S. fibuligera and its hybrid will provide in-depth insights into fungal genome dynamics as evolutionary adaptation.

Lungurra Ngoora--a pilot model of care for aged and disabled in a remote Aboriginal community--can it work?

INTRODUCTION

The literature on the health of and services for older Aboriginal and Torres Strait Islander populations is relatively sparse. This study explored the development and implementation of a locally designed community service model of care for older people, and people with disability and/or mental health problems in remote Aboriginal Australia.

METHODS

Based on extensive community consultation with older people, families, carers, community members and stakeholders, a model of care was developed to address unmet needs for the target population and their carers in the remote community of Looma, in the Kimberley region of Australia. The model was implemented and evaluated over 12 months. The main outcome measures included the number of services (including home services, meals, transport, respite, personal care and advocacy) provided. Outcomes of community participation, capacity building, resources, partnerships, workforce, service delivery and cultural protection were assessed qualitatively by an external evaluator.

RESULTS

The number of people receiving community care services in Looma increased from eight to 22, and services increased in all domains from 140 total services delivered for 1 month at baseline to 2356 by the final month of the program.

CONCLUSIONS

The Lungurra Ngoora community care service model pilot project demonstrated a successful collaborative service model that addressed the care needs of older persons, those with disability and mental illness, and their carers in this remote community. The developmental approach, and model structure, could serve as a template for future delivery of services in remote Aboriginal communities.

'Gotta be sit down and worked out together': views of Aboriginal caregivers and service providers on ways to improve dementia care for Aboriginal Australians

INTRODUCTION

Dementia is five-fold more prevalent among Aboriginal than non-Aboriginal Australians. Despite this, the quality of care available to people living with dementia in remote Aboriginal communities is poor. The objective of this study was to determine ways to overcome factors affecting the successful delivery of services to Aboriginal people with dementia living in remote communities, and to their families and communities.

METHODS

This qualitative research took place in the Kimberley Region of Western Australia. Data collection occurred in three stages: (1) interviews with service providers to identify the services available; (2) interviews with the caregivers of Aboriginal people living with dementia and community-based care workers; and (3) focus groups with community representatives and community care staff. Each stage was concluded when no new themes emerged. At each stage the transcribed information was analysed and joint interpretation identified common themes.

RESULTS

In total, 42 service providers, 31 caregivers and community-based care workers were interviewed and 3 focus groups were conducted. Obstacles to accessing quality care were mentioned and recommendations on ways to improve care were made. The key themes that emerged were caregiver role, perspectives of dementia, community and culturally-appropriate care, workforce, education and training, issues affecting remote communities and service issues. Detailed information on how each theme affects the successful delivery of dementia care is provided.

CONCLUSIONS

These research findings indicate that people living with dementia and their caregivers in remote Aboriginal communities are struggling to cope. They are requesting and require better community care. Implementing a culturally safe model of dementia care for remote Aboriginal communities that encompasses the recommendations made and builds on the strengths of the communities could potentially deliver the required improvements to dementia care for this population.

Differential effects of a saturated and a monounsaturated fatty acid on MHC class I antigen presentation

Lipid overload, associated with metabolic disorders, occurs when fatty acids accumulate in non-adipose tissues. Cells of these tissues use major histocompatibility complex (MHC) class I molecules to present antigen to T cells in order to eliminate pathogens. As obesity is associated with impaired immune responses, we tested the hypothesis that the early stages of lipid overload with saturated fatty acids (SFA) alters MHC class I antigen presentation. Antigen presenting cells (APC) were treated with either the saturated palmitic acid (PA), abundant in the high fat Western diet, or the monounsaturated oleic acid (OA), a component of the Mediterranean diet. PA-treatment lowered APC lysis by activated cytotoxic T lymphocytes and inhibited APC ability to stimulate naïve T cells. Inhibition of immune responses with PA was due to a significant reduction in MHC class I surface expression, inhibition in the rate of APC-T-cell conjugation, and lowering of plasma membrane F-actin levels. OA-treatment had no effect on antigen presentation and upon exposure with PA, prevented the phenotypic effects of PA. OA-treatment conferred protection against changes in antigen presentation by accumulating fatty acids into triglyceride-rich lipid droplets of APC. Our findings establish for the first time a link between the early stages of lipid overload and antigen presentation and suggest that dietary SFA could impair immunity by affecting MHC I-mediated antigen presentation; this could be prevented, paradoxically, by accumulation of triglycerides rich in monounsaturated fatty acids.

Although substantial (qol) quality of life problems may occur due to acute and delayed complications of therapy for advanced head & neck squamous cancer, overall long term qol is good/acceptable

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Background: Patients with locally advanced head and neck squamous cell cancer (HNSCCA) have traditionally been treated with aggressive regimens of concurrent chemo-radiation, or more recently, induction chemotherapy followed by concurrent chemo-radiation, to achieve high rates of tumor control at our institution. Objectives: We initiated a QOL study in patients who were free of tumor and available for long term follow up with a focus on acute & delayed complications and long term QOL observation. Methods: The study included 75 patients with stage III-IV HNSCCA treated with either concurrent chemo-radiation or induction chemotherapy followed by concurrent chemo-radiation at our institution. All patients had completed therapy and were considered free of disease at the time of survey. We were unable to complete the survey in 43 pts largely due to patient access problems or unavailability at time of survey. In the remaining 32 patients, the University of Washington QOL survey could be completed over the telephone. Two pts were excluded due to recent demonstration of recurrence. Additional information regarding acute toxicity during treatment was also recorded. Results: There were 11 women and 19 men with a median duration of follow up of 36 months (range 3–120 months) after completion of treatment. Early complications were associated with gastrostomy tube placement (5 leaks & 6 infections,12/31 patients, 38.7%) and portacath placements (2 deep vein thrombosis requiring port removal and anticoagulation, 6.45%). No patients in this group were still dependent on their gastrostomy tube for nutrition at the time of follow up. Of note, 9% of patients were still smoking and drinking on a regular basis. The composite scores for 9 QOL domains ranged from 370–875, with a median score of 615/900. Major problem issues regarding QOL were associated saliva 11/31 (35.5%), swallowing 10/31 (32.2%), followed by mood 6/31 (19.3%), pain 5/31 (16.12%), chewing 4/31 (12.9%), local pain 5/31 (16.12%) and shoulder problems 5/31 (16.12%). Conclusion: Initial QOL problems in advanced HNSCCA appear related to surgical/chemo therapy related problems, whereas late QOL issues appear primarily related to radiation. Most patients however had a good or acceptable quality of life after treatment for advanced HNSCCA.

No significant financial relationships to disclose.

Dissociation of lexical syntax and semantics: evidence from focal cortical degeneration

The question of whether information relevant to meaning (semantics) and structure (syntax) relies on a common language processor or on separate subsystems has proved difficult to address definitively because of the confounds involved in comparing the two types of information. At the sentence level syntactic and semantic judgments make different cognitive demands, while at the single word level, the most commonly used syntactic distinction (between nouns and verbs) is confounded with a fundamental semantic difference (between objects and actions). The present study employs a different syntactic contrast (between count nouns and mass nouns), which is crossed with a semantic difference (between naturally occurring and man-made substances) applying to words within a circumscribed semantic field (foodstuffs). We show, first, that grammaticality judgments of a patient with semantic dementia are indistinguishable from those of a group of age-matched controls, and are similar regardless of the status of his semantic knowledge about the item. In a second experiment we use the triadic task in a group of age-matched controls to show that similarity judgments are influenced not only by meaning (natural vs. manmade), but also implicitly by syntactic information (count vs. mass). Using the same task in a patient with semantic dementia we show that the semantic influences on the syntactic dimension are unlikely to account for this pattern in normals. These data are discussed in relation to modular vs. nonmodular models of language processing, and in particular to the semantic-syntactic distinction.

Patient dose variation investigated in four Irish hospitals for barium meal and barium enema examinations

Four hospitals have been studied, intra- and inter-hospital variations examined and the mean DAP values recorded for barium enemas and barium meals. Mean DAP values for barium meals and barium enemas at 11.4 Gy x cm2 and 20.1 Gy x cm2 respectively have been shown. Differences between individual examinations for barium meals varied by up to a factor of 185 and for barium enemas, up to a factor of 19, with hospital means for barium meal and enema examinations each differing by up to a factor of 3. The data provided by this study have suggested that large variations in patient dose do exist in Ireland for barium meal and barium enema examinations. Fluoroscopy time was shown to be a major contributor to the variations reported, with number of images playing a minor role. Results have demonstrated the need for standardisation of technique throughout the country for these examinations.

Adolescents' relationships to siblings and mothers: a multivariate genetic analysis

Research has consistently demonstrated that children's behavior toward their siblings tends to resemble interactions occurring in the parent-child relationship. This study examined the relative contributions of genetic and environmental influences to the covariation between sibling relationships and mother-adolescent relationships. Reported and observed family interactions were assessed for 719 same-sex sibling pairs of varying degrees of genetic relatedness. The covariance between mother-adolescent and sibling interactions was decomposed into genetic, shared, and nonshared environmental components. The overlapping effects of shared environment on the two relationship subsystems explained most of the covariance. Smaller but significant genetic and nonshared environmental effects were also found. The consistency of these findings with family processes, such as modeling, is discussed.

Paroxetine open-label treatment of pediatric outpatients with obsessive-compulsive disorder

OBJECTIVE

Paroxetine is a selective serotonin reuptake inhibitor with demonstrated efficacy in treating obsessive-compulsive disorder (OCD) in adults. This study evaluates the safety and effectiveness of paroxetine in pediatric OCD patients.

METHOD

In a 12-week, open-label trial of paroxetine, 20 OCD outpatients, aged 8 to 17 years, were treated for OCD with daily doses ranging from 10 to 60 mg. Target symptoms were rated at regular intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the Children's Global Assessment Scale, the Clinical Global Impression Scale, the Hamilton Anxiety Rating Scale, and the Yale Global Tic Severity Scale.

RESULTS

Paroxetine proved relatively safe in this brief trial with a small sample and appeared to be effective in patients with OCD; mean CY-BOCS scores decreased significantly (z = 3.49, p = .0005) from 30.6 +/- 3.5 to 21.6 +/- 6.8 on medication. The most common side effects (n > or = 2) were hyperactivity/behavioral activation, headache, insomnia, nausea, and anxiety. Paroxetine did not have to be discontinued in any of the patients because of side effects; the most serious side effects included hyperactivity/behavioral activation in 3 younger patients (< 10 years) necessitating dosage reduction but not discontinuation.

CONCLUSIONS

Preliminary evidence suggests that short-term treatment of pediatric OCD outpatients with paroxetine may be relatively safe and effective.

Thermodilution measurement of cardiac output in patients with low output: room-temperature versus iced injectate

BACKGROUND

Measurements of cardiac output with the thermodilution technique add to data for clinical decision making and therefore must be valid and reliable. However, the results of studies on the accuracy of values obtained with room-temperature and iced injectates, especially in patients with high or low cardiac output, have been conflicting.

OBJECTIVE

To determine the effect of the temperature of the injectate (iced or room temperature) on cardiac output values obtained with the thermodilution technique in critically ill adults with known low cardiac output.

METHODS

A convenience sample of 50 subjects (41 men and 9 women) who had a cardiac index of less than 2.5 (calculated as cardiac output in liters per minute divided by body surface area in square meters) before the study had cardiac output measured by using a closed system and manual injections of room-temperature and iced injectates.

RESULTS

A paired t test indicated no significant difference between iced and room-temperature injectates for cardiac output (iced, 3.62 L/min; room temperature, 3.71 L/min; t = 0.99; P = .327) and cardiac index (iced, 1.95; room temperature, 1.99; t = 0.71; P = .482).

CONCLUSION

The findings support the practice of using room-temperature injectate to measure cardiac output in patients with low cardiac output.

Thermodilution measurement of cardiac output in patients with low output: room-temperature versus iced injectate

BACKGROUND: Measurements of cardiac output with the thermodilution technique add to data for clinical decision making and therefore must be valid and reliable. However, the results of studies on the accuracy of values obtained with room-temperature and iced injectates, especially in patients with high or low cardiac output, have been conflicting. OBJECTIVE: To determine the effect of the temperature of the injectate (iced or room temperature) on cardiac output values obtained with the thermodilution technique in critically ill adults with known low cardiac output. METHODS: A convenience sample of 50 subjects (41 men and 9 women) who had a cardiac index of less than 2.5 (calculated as cardiac output in liters per minute divided by body surface area in square meters) before the study had cardiac output measured by using a closed system and manual injections of room-temperature and iced injectates. RESULTS: A paired t test indicated no significant difference between iced and room-temperature injectates for cardiac output (iced, 3.62 L/min; room temperature, 3.71 L/min; t = 0.99; P = .327) and cardiac index (iced, 1.95; room temperature, 1.99; t = 0.71; P = .482). CONCLUSION: The findings support the practice of using room-temperature injectate to measure cardiac output in patients with low cardiac output.